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A recent paper in Annals of Surgery looks at the rate of resident remediation over a decade or so at six general surgery programs in California. The authors reviewed the records of 348 categorical general surgery residents and found that 107 (31%) required mediation with knowledge deficits the primary reason in 74%. Other issues, such as interpersonal and communication skills, patient care and professionalism, were cited far less often.

Need for remediation did not correlate with attrition. Remediated residents left programs at a rate of 20% compared to 15% of non-remediated residents, p = 0.40.

On multivariate analysis, only two factors were associated with the need for remediation. One was USMLE Step 1 scores, which were lower in the remediated group. But the median difference in scores between remediated and non-remediated residents was only 7 points with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.

The other factor was quite remarkable. Remediated residents were significantly more likely to have received a grade of "honors" for their medical school clerkship and surgery. How can this be?

The authors speculated, "One thought is that medical students start residency underprepared for the rigors of surgical residency." Now where I heard that before? I have previously blogged on General Surgery News (here) about the unrealistic third-year experiences of medical students on surgical rotations. While I agree that they likely are not ready for the workload, I'm not sure what it has to do with the primary reason for their poor performance—a perceived knowledge deficit. Does hard work cause them to forget everything they’ve learned or are they taught the wrong stuff in med school?

I think not. The real reason may be found in the way medical students are graded. A group from Harvard looked at medical school grading systems and found that honors grades in third-year surgery clerkships are given to an average of about 30% of students ranging from a low of 7% to an mind-boggling high of 67%. I understand that those accepted to med school are smart, but how is it that two-thirds of the class can achieve honors in surgery? Could it be that some of the honors grades given to residents who eventually needed remediation were not warranted?

If you would like to read more about grades in medical school, you may read the full text of the paper here or a summary on my personal blog.

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 300,000 page views, and he has over 3700 followers on Twitter.

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Comments: (5)show:

skept...wrote on: 11/7/2012 1:05 PM (EST)846 days ago

I apologize for not responding to these excellent comments sooner. Regarding the sleep issue, I thought the work hours reform was supposed to solve that. It turns out that a paper last month in Annals of Surgery shows ortho residents are averaging about 5 hours of sleep per night, which is not changed from before the work rules changes. They also feel less prepared. [http://journals.lww.com/annalsofsurgery/Abstract/publishahead/Long_Term_Follow_Up_on_the_Educational_Impact_of.98627.aspx]
I agree that the "T-ball" mentality is upon us and have blogged about that issue. [http://skepticalscalpel.blogspot.com/2012/10/medical-school-grading-and-t-ball.html]
I have also said that we teach surgery the same way we did 40 years ago. Why memorize a bunch of stuff you can carry in your phone? Why not teach them how to think instead? [http://skepticalscalpel.blogspot.com/2012/07/things-that-puzzle-me-about-surgical.html]
Yes, there is still too much scut work. Residents spend time filling out discharge forms, transfer forms, etc.

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TMDNY...wrote on: 10/27/2012 2:14 AM (EST)857 days ago

I believe that too many hours are spent on work,and not on educating the resident.When you work in a surgical residency,you never have time to read at least 3-4 hours a day.Too much time is spent on floor and unit rounds,clinic,OR,pre-ops,and ER consultations.Not enough time is spent on lecture topics.Every time you try to read something else pops up,and there goes your studying.
Surgical education must become more educational,allowing residents to read daily,and utilize practice questions.If this is obtained,higher in service scores will be obtained.

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drark...wrote on: 10/25/2012 5:23 PM (EST)859 days ago

I believe that the poor performance is based on many issues. Often third year students receive non-standardized education without a specific curriculum. Their education often is "trickle down"; attending to Fellow,to chief Resident to senior resident, etc.When it comes to the student, there may not be much educational value left on that rotation. Also, the grade may come from the residents or a report to the attending from the residents. We are now experiencing, in my opinion, a "know it for the test" mentality. Pass the exam, move on, and forget it. My last observation is that of Hand held Knowledge. Why learn "this stuff", if it's right here on my I-pad, Laptop, cellphone? I do agree that limited work hours and over work on the other hand have a bearing on their performance, but even with limited work hours, is that resident studying, sleeping, or socializing? Maybe bed checks will solve the fatigue problem so that the residents will do a better job.

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wmbii...wrote on: 10/25/2012 3:31 PM (EST)859 days ago

Once again, the etiology for this problem can be laid squarely at the decline, or sissyfication, or our society as a whole. With work hour limits squelching learning opportunities and shielding residents from the almost-all-consuming nature that surgical residencies used to be, this is what we get.

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jawol...wrote on: 10/25/2012 2:27 PM (EST)859 days ago

I disagree with the author's thesis, that "honors" clerkship students somehow don't deserve their grades. The critical difference is the circumstance under which learning is done. The medical student enjoys didactic teaching, as well as time to read, memorize, and reflect. The surgical resident (at least in my day) received none of the above. We were merely servants for the professors, who were more interested in their grants and research papers than in their residents or patients. My reading time took place in the dead of night, often while marching in place and smoking cigarettes to stay awake. I was fatigued and depressed all the time. There were far too many shameful moments when, in my utter exhaustion, I would gladly have allowed a patient to suffer if I could garner only a few minutes of sleep. Under such stressful circumstances, many people would be unable to perform academically. The fault isn't with the residents. It is the fault of the inhumane academic system and the "good old boys" who run it.